Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    All neuropsychological testing requires preauthorization. This includes performance of standardized cognitive performance testing such as the Ross Information Processing Assessment.

2)    Neuropsychological testing is used to aid in the assessment of cognitive impairment due to medical conditions. Testing is generally done by specially trained psychologists.

3)    Neuropsychological testing is generally covered by QualChoice when rendered for the diagnosis or evaluation of stroke or head injury with neurologic deficit.

4)    Neuropsychological testing may be covered for assessment of neurocognitive abilities related to other medical diagnoses, when the results of the testing will directly influence management of the patient’s condition. 

5)    The number of hours or units requested for testing should not exceed the reasonable time necessary to address the clinical questions with the identified measures. Usual testing time is four (4) to six (6) hours to perform (including administration, scoring, and interpretation.) For more than 6 hours of testing, medical necessity for the extended testing should be documented. Extended testing for more than 8 hours is not covered.

6)    Computerized neuropsychological testing that does not require professional interpretation and report is not covered.

7)    Use of telemedicine services for providing neuropsychological testing is not covered.

1)    Neuropsychological testing (NPT) is considered medically necessary for cognitive evaluation when:

a)    There is a significant cognitive deficit, mental status abnormality, behavioral change, or memory loss that requires quantification or differentiation of cause, AND

b)    The suspected or known cause is one of the following:

i)     Multiple sclerosis (G35)

ii)    Dementia or other cognitive impairment as initial evaluation when diagnosis or severity is unclear (F01.50 – F03.91, G30.0 – G31.1)

iii)   HIV, Lyme disease, herpes encephalitis, or other infection associated cognitive disorders when there is a need for evaluation of significant cognitive deterioration (A69.20 – A69.29, B00.4, B20)

iv)   Primary progressive aphasia (G31.01)

v)    Cerebrovascular disease (I60.00 – I69.998)

vi)   Huntington disease (G10)

vii) Traumatic or anoxic brain injury (S06.0X0A – S06.9X9S)

viii)  Parkinson disease (G31.83)

ix)   Hydrocephalus (G91.0 – G91.9)

x)    Postsurgical change assessment in epilepsy

xi)   Cerebral dysfunction from known toxic exposure (T51 – T65 w/G92)

xii)   Cerebral mass (G93.9)

xiii)  Toxic effects of specific cancer treatment, AND

c)    There is an absence of active substance use, withdrawal, or recovery from recent chronic use

2)    NPT is medically necessary to aid in the diagnosis or exclusion of an organic or behavioral health disorder when ALL of the following are met:

a)    Detailed medical, neurologic, mental status, and psychiatric exams have been done as indicated

b)    Detailed medical diagnostic testing has been done as indicated

c)    Known potential causes have been adequately treated

d)    Significant findings, behaviors, or deficits persist without identified cause

e)    Proposed testing can answer a question that psychiatric evaluation, observation in therapy, or other assessment cannot.

3)    NPT is not considered medically necessary for diagnosis, evaluation, or treatment of attention deficit disorders, as there is no evidence in the medical literature to support its use in this setting.

4)    NPT is a diagnostic test and is not considered medically necessary for ongoing or recurrent monitoring of progression of cognitive impairment secondary to neurological or degenerative disorders.

Codes Used: